What is the HANDI project?

HANDI is aimed at promoting effective non-drug treatments for general practice/primary care. Non-drug treatments, in the broadest sense, refer to any intervention that would not normally appear in a pharmacopoeia including exercise, physical therapies, diets, behaviour change interventions, supplements and herbal treatments.

The HANDI team (the Committee) only consider the assessment of non-drug treatments that are relevant to primary care which might be classed as:

• Category 1: Interventions performed by a GP or other primary care clinician (eg The Epley manoeuvre)
• Category 2: Interventions performed by the patient under the GP/primary care clinician’s guidance (eg wet combing)
• Category 3: Interventions usually performed by the GP/primary care clinician that can be taught to patients under special circumstances (eg Stretching exercises for plantar fasciitis)
• Category 4: Interventions that require referral after initial assessment from GP/primary care clinician (eg IBS referral for FODMAP, or psychologist referral for CBT or depression).

Category 4 is only considered for assessment under the following conditions:

• the non-drug intervention is not assumed knowledge and widely known by GPs/primary care clinicians
• the non-drug intervention is not assumed to be the routine therapy for that condition (eg FODMAP diet for IBS)

It is important to note HANDI is not a clinical guideline as it does not compare and rank alternative interventions. HANDI entries are presented much like a medical pharmacopoeia lists medicine.

Topic selection

The HANDI team collect possible topics from a variety of sources including online evidence summaries (eg ACCESS and Cochrane databases), suggestions from the Committee members and suggestions posted to the HANDI website.

Committee members choose topics that are relevant to general practice and for which there is Randomised Controlled Trial (RCT) evidence. This is followed by a search for systematic reviews and subsequent trials.

Each potential HANDI entry then goes through a 3-stage process before being published.

Stage 1: Assessing the evidence and relevance

The Committee assess the effectiveness of the proposed non-drug intervention in this stage. Individual members present their assessment to the team, using a standard assessment template, followed by general discussion and a voting process. The Committee consider two questions for assessing inclusion in the handbook:

1. Is the quality of the evidence strong enough?
2. Is the intervention relevant to and practical for general practice teams?

For inclusion in HANDI interventions must be supported by at least two good quality RCTs with patient-relevant outcomes, or one RCT with strong supportive evidence for the causal connection under investigation. Interventions may be included where evidence is rated as relatively lower quality, if there are minimal or no downsides to the patient ie benefits clearly outweigh possible harms.

At this first stage the Committee note issues that need to be considered in drafting the handbook entry.

Criteria for inclusion in HANDI are high; despite looking only at treatments with promising evidence, about half of the proposed interventions based on the criteria above are rejected.

Using GRADE for HANDI entries

The RAGCP initially used the NHMRC levels of evidence for evidence evaluation and transitioned to using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology in 2020.

GRADE allows rating of both the certainty of the evidence and also the strength of recommendations. However, HANDI only states the Quality of Evidence, expressed as Certainty (Very Low, Low, Moderate, High) and does not state strength of recommendations as is done with guidelines. This is because HANDI is not a clinical guideline as it does not compare and rank alternative interventions. HANDI entries are presented much like a medical pharmacopoeia lists medicines.

Stage 2: Drafting the HANDI entry

If the quality of evidence is acceptable and the intervention is relevant to general practice, the intervention is then included.

The Committee works with a medical editor, with trial authors and other experts in the type of intervention where possible, to develop a detailed “how to” guide for the use of the non-drug intervention.

The format is similar to that of a drug formulary. It includes indications, contraindications, precautions, adverse effects, availability, practice tips and a description of the intervention. It also includes consumer resources, where available.

Stage 3: Final review

Once drafted, the entry is reviewed by the committee and the RACGP’s Expert Committee-Quality Care, prior to finalisation and publication onto the HANDI website.

The committee currently meets quarterly and considers up to four new potential entries at each meeting. Discussion typically includes: the evidence for new possible entries; development of draft entries; and the review and update of existing entries.

The RACGP gratefully acknowledge funding received from the Jack Brockhoff Foundation (2012-2013) and BUPA Foundation (2013-2016) to develop the HANDI project.

The RACGP gratefully acknowledge funding received from the Medibank Health and Research Fund (2018-2020) for the further development of HANDI resources.